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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part III-New Approaches: Innovations to Address Homelessness & Health

Chapter 12. Collaborative Approaches to Community-Based Mental Health Care for Homeless People: Toronto's Inner City Health Associates

Vicky Stergiopoulos

Texte intégral

Introduction

1Several recent reports have reviewed the health consequences and costs of homelessness in Canada (cihi 2007; Patterson et al. 2008). Homeless persons in Western countries have high rates of mental health challenges and addiction and approximately one-third have a severe mental illness (cihi 2007). A recent systematic review and meta-analysis of mental disorders among homeless persons in Western countries reported pooled preva0lence rates of 12.7 percent for psychotic disorders, 11.4 percent for major depression, 37.9 percent for alcohol dependence and 24.4 percent for drug dependence (Fazel et al. 2008). Furthermore 4 percent to 7 percent of homeless persons experience global cognitive deficits, and many more experience focal deficits in verbal or visual memory, attention, executive function and speed of cognitive processing (Burra, Stergiopoulos and Rourke 2009). These rates are much higher than mean prevalence rates reported for these conditions in the general population.

2Not surprisingly, the risk of homelessness among individuals with serious mental illness is 10 to 20 times higher than the general population, and 4 percent to 36 percent of psychiatric hospital patients experience homelessness before or after their hospital stay (Susser et al. 1997; Kuno et al. 2000). Homeless persons with mental illness and addictions are at increased risk of experiencing chronic homelessness and utilize more health and social services than others experiencing homelessness (Aubry, Klodawsky and Hay 2003; cihi 2007). Furthermore, many chronically homeless persons with mental illness have multiple and complex physical health needs including infectious diseases, chronic medical conditions and physical disabilities (Hwang 2001). In addition to mental and physical illness, homeless persons experience high stress levels and low self-esteem and report poor coping skills and suicidal behaviours (cihi 2007). Mortality among homeless persons is much higher than the general population, and many unexpected deaths among homeless people in Canada are related to mental disorders and suicides (Hwang 2000; Hwang et al. 2009).

3Toronto is home to Canada's largest homeless population, with over 5,000 people experiencing homelessness on any given night (City of Toronto 2009). More than three-quarters (79%) of those live in shelters, 8 percent live on the street, 6 percent in correctional facilities, 4 percent in health care or treatment facilities and another 3 percent in transition shelters for women who have experienced domestic violence. Over the course of the year, approximately 28,000 unique individuals use homeless shelters in Toronto (City of Toronto 2009). Similar to those in other jurisdictions, homeless persons in Toronto have complex health needs. A 1998 study reported that 67 percent of a representative sample of shelter users in Toronto have a lifetime diagnosis of a mental illness (Mental Health Policy Research Group 1997; cihi 2007). The more recent 2007 Street Health Report (Khandor and Mason 2007) identified that 35 percent of Toronto homeless respondents had been previously diagnosed with a mental illness, with the most common diagnoses reported being depression (17%), anxiety (11%), bipolar affective disorder (8%), schizophrenia (5%) and post-traumatic stress disorder (5%). Approximately 25 percent of respondents reported a concurrent mental health and substance use disorder.

4Despite Canada's universal health care system, few homeless persons in Toronto are connected to a regular health care provider. Furthermore, it is estimated that 75 percent of those diagnosed with a mental illness have not had a psychiatric outpatient contact in the previous year (cihi 2007). Even those accessing health services have a high rate of unmet needs, as they often receive services that do not match the level of care they require (Stergiopoulos et al. 2010a). A study at Ontario's largest shelter for homeless men revealed that 38 percent of the clients required intensive case management or assertive community treatment and 9 percent required 24-hour supervision in a residential care facility. Despite the presence of primary care services on site, half the men did not have their service needs met (Stergiopoulos et al. 2010a).

5Finally, unlike major US urban centres, Toronto has not developed a coordinated approach to homeless health service provision. Local services for homeless persons include a range of supportive and alternative housing, emergency shelters, drop-ins, street outreach teams, housing help and eviction prevention services, meal programs and a nurse led health bus, funded by both government and nonprofit organizations. More recently, the City of Toronto launched a Streets to Homes program, which focuses on moving homeless individuals living outdoors into housing (City of Toronto, Shelter, Support and Housing Administration 2009). In addition to these homeless specific services, there is a resource-rich health service network accessible to both homeless and housed individuals, including nurse and physician primary care providers, community health centres, in-patient and outpatient specialty care, case management, assertive community treatment, early intervention for psychosis programs, court support services and mobile crisis intervention teams, amongst others.

6Despite the large range of services and supports, homeless persons with mental illness and addictions face major barriers to accessing services that can meet their needs. Access to comprehensive care is limited, discharge planning from hospitals is poor and coordination and collaboration among service providers and service sectors, including housing, income support and health programs, is lacking (Goering et al. 2004). Physician care specifically remains challenging to access because medical and hospital care require a valid provincial health card, which many homeless persons do not possess. Furthermore, physicians are remunerated on a fee for service model, which fails to adequately compensate for much of the indirect and complex care involved in addressing the health needs of this population.

7To effectively address these barriers and support the complex health needs of homeless people with mental health and addiction problems, comprehensive interventions that address their needs and preferences must be designed and implemented (Stefancic and Tsemberis 2007). This chapter describes the efforts of Toronto's Inner City Health Associates (icha) to address some of these challenges through targeted placement of physicians in frontline homeless service settings and through the development of innovative collaborative models of service delivery in partnership with frontline health and social service providers. It also discusses the lessons learned in the efforts to build community capacity and to promote hospital and community integration and the integration of health and social service delivery. These lessons may be instructive for other jurisdictions facing similar barriers to accessing comprehensive care for homeless people with mental health and addictions problems and can support efforts to improve care for this vulnerable population.

Toronto's Inner City Health Associates (ICHA)

8St. Michael's Hospital, Toronto's urban teaching hospital, has a long history of working and planning collaboratively with local community partners to improve care for the poor and the underserved. Following persistent advocacy efforts by a small group of St. Michael's physicians and administrators, the Ontario Ministry of Health and Long Term Care negotiated an alternate payment plan to facilitate recruitment of family physicians, psychiatrists and other specialists into frontline homeless service settings, many of which are located within blocks of the hospital. To our knowledge, this was the first such alternate payment plan in Canada. The funding addressed physician compensation, a barrier to recruitment in the past, but provided no administrative or other health provider infrastructure. This limitation necessitated building extensive inter-agency and inter-sectoral partnerships and collaborations to coordinate medical care with frontline homeless social services and other health supports through innovative, collaborative models of service delivery.

9In recent years, there has been increased interest in community participation in the design of health services, in an effort to improve the quality of health care (Institute of Medicine 2004). Using the principles of community-based participatory research, the efforts of health planners and policy-makers have increasingly focused on including local stakeholders, patients and their families in the redesign of local systems of care for the purpose of system improvement. Keyser and colleagues (2010) have recently outlined the steps taken for mobilizing a region to redesign its local system of care. Action steps in their efforts have included forging partnerships with local funders and policy-makers; involving all relevant system players in the collaborative change process; prioritizing community goals for system change; understanding barriers and issues faced by local providers and program staff who work in the system; learning from national and local programs; identifying potential policy levels and, finally, developing a blueprint for community action and sustainability (Keyser et al. 2010). In a similar fashion, given its intent to act on behalf of the community it serves, icha organized internally and aimed to set the stage for planned local system change through three broad approaches: (1) developing partnerships with local stakeholders, (2) collaborative planning and program development and (3) collaborative organizational program structures. Planning had a clear focus on addressing access to health care for homeless people and frontline social service providers and recognized the diversity of needs and perspectives of local stakeholders. It relied on frequent communication, commitment to optimal use of expertise and resources and regular review and evaluation. The framework for change was clearly set by community-driven needs assessment efforts and was informed by an extensive review of the literature.

10Previous local studies have documented multiple unmet health needs among homeless persons, with less than one-third of homeless persons with mental illness in Toronto receiving treatment (Mental Health Policy Research Group 1997; Stergiopoulos et al. 2010a). Furthermore, an assessment of the health, mental health and addiction treatment needs of people using emergency shelters in Toronto highlighted the lack of coordination and collaboration among health and social service providers, leading to fragmentation, duplication and gaps in services (Goering et al. 2004).

11Drawing on the findings and recommendations of these needs assessments, icha identified two key domains upon which to focus initial change efforts: (1) community engagement and (2) care coordination/service integration. icha program planning began with extensive consultations with the City of Toronto's Shelter, Support and Housing Administration Division, the Toronto Drop-In Network and several local health and social services planning groups to ensure homeless health care needs were addressed across geographical areas and service- and population-specific sectors. icha embarked on further extensive local needs assessments, including individual and focus group interviews of program planners, service providers and people with lived experience of homelessness, to identify perceived strengths, weaknesses and opportunities in each geographic area within the city, service priorities and needs of clients and service providers and directions for effective and inclusive planning and communication, including the principles upon which to base partnership development, planning and collaboration.

12Different models of frontline health care provision were developed, depending on client needs and resources available at each service site. Models ranging from integrative and consultative collaborative care models (Stergiopoulos, Rouleau and Yoder 2007; Tam 2010) to intensive case management and assertive community treatment team models (Stergiopoulos et al. 2010a) were developed to facilitate access to the different levels of care that homeless clients with complex health needs require. Given that icha only has access to physician funding and that health services for homeless persons remain un-integrated and poorly coordinated, these models depended on successful partnerships and collaboration with a range of other health and social services providers, including shelter and drop-in counsellors, homecare nurses and community mental health case managers.

13icha currently numbers 65 physicians, including 32 psychiatrists, 29 family physicians and 4 other specialists, and provides medical and psychiatric care to more than 40 frontline homeless service agencies, including men, women, family and youth shelters, drop-ins, street outreach teams and select supportive housing agencies serving homeless persons with complex health needs. The group served more than 1,700 people in 2010, providing approximately 5,700 hours of primary care and 8,700 hours of psychiatric care. icha physicians provide direct and indirect care, advise frontline staff on service and case management plans, and teach on selected topics in efforts to build community capacity. They also advocate to different service sectors to help coordinate care and ultimately connect homeless people to mainstream services and supports. icha physicians are recruited to provide recovery-oriented care from a harm reduction framework, focusing on the determinants of community health. They prioritize housing, income and social support in their treatment plan. In addition to direct and indirect care to homeless people with complex health needs and development of community capacity, icha has identified student and resident education as a priority. A number of elective, selective, career-track and research opportunities for medical and other health discipline students, residents and fellows have been made available. Most icha physicians are affiliated with the University of Toronto and have primary appointments at one of the affiliated teaching hospitals, spending only a small portion of their clinical time in homeless service settings. They also advocate, within their mainstream service settings, for services that are respectful and responsive to the needs of clients who experience homelessness or housing instability.

14This approach is unlike other attempts to organize care for homeless persons, in advocating for better use or coordination of existing services and supports though integrated planning and collaboration, rather than creating a parallel system of homeless health care. icha services aim to create a gateway to mainstream services and supports by engaging and providing a healing relationship to patients who may have experienced stigma and discrimination in past health encounters and by developing the capacity of both mainstream health and frontline homeless social service providers to address the complex needs of homeless persons comprehensively, developing and using best practice models.

Bringing Services Together through Partnerships and Collaborations

15icha program development addresses needs for preventive care, management of acute illness and comprehensive management of chronic complex health needs. The following sections describe some of the programs developed through partnerships and collaborations over the past seven years.

Shelter and Drop-in Based Collaborative Mental Health Care Teams

16Collaborative mental health care is an important component of health care reform in many countries (Craven and Bland 2006). This term refers to models of practice in which patients, their caregivers and health providers from a variety of primary care and mental health settings work together to provide timely and better-coordinated services for individuals with mental health problems. Given the complex physical, mental health and social service needs of homeless persons, collaborative mental health care is an intuitively appealing service model. Since 2005, both consultative and integrative models of collaborative mental health care have been developed in the largest men, women and youth shelters and drop-ins in Toronto. These enable rapid evaluation and treatment of patients with a wide range of mental health problems, improve the ability of shelter and dropin staff to manage them, improve the education of shelter staff and trainees on the needs of homeless persons and reduce reliance on emergency department visits and hospitalizations for unmet mental health needs.

17Fusion of Care, developed at Seaton House, one of Canada's largest shelters for homeless men, is an integrated collaborative care model with on-site medical support and a flexible referral process. In this model, shelter staff and icha physicians work as a single team. The impetus for adopting this model of service delivery was the communication breakdown and lack of coordination in care delivery experienced when case management or medical care of clients was brokered to external agencies (Stergiopoulos, Rouleau and Yoder 2007). The Fusion of Care Team provides medical care and in-house case management to the clients of the 240-bed Hostel Program, one of Seaton House's seven programs, and has the capacity to serve 40 clients at any one time. The team consists of a client service worker, a counsellor, a nurse and a team leader/counsellor, all Seaton House full-time staff, as well as a family physician and a psychiatrist. The two icha physicians offer concurrent clinics at the shelter for a half day every week, working collaboratively through both direct and indirect consultations.

18The target population is chronically homeless persons whose health needs exceed the hostel's resources and who are unable to access community-based services. Once a client is identified by hostel staff as a candidate for the program, the client meets with a counsellor for one hour to set goals and complete a comprehensive psychosocial assessment. The client subsequently meets with the team nurse for a comprehensive health assessment. Once the main health issues are identified, the client is referred, depending on the complexity and acuity of health needs, to either a family physician or a psychiatrist. A comprehensive care plan is developed during weekly multidisciplinary team rounds for each client. The client service worker facilitates adherence to the plan by escorting clients to appointments off site and provides team members feedback and information about the client's function, hygiene and behaviour. Medications are dispensed daily to clients by the team's nurse. Although a rigorous evaluation is under way, preliminary program evaluation results are promising. A chart review of 73 clients referred over a 12-month period revealed that six months after intake into the program 35.3 percent had improved clinically and 48.5 percent were housed. Factors associated with positive outcomes included the number of visits with a psychiatrist and treatment adherence (Stergiopoulos et al. 2008).

19Consultative rather than integrative collaborative care models have been developed in other settings not resourced to support integrated teams. For example, at Agincourt Community Services, a community centre serving homeless and under-housed people at the city's east end, a psychiatrist provides consultation services to the agency's housing and outreach programs, working closely with drop-in staff. Agency case managers frequently attend appointments to ensure care is seamless and coordinated. In addition to supporting frontline staff and clients, the psychiatrist, in collaboration with Toronto Social Services, completes disability assessments to facilitate access to income support for eligible homeless persons (Tam 2010).

Multidisciplinary Outreach Team (MDOT)

20An inter-agency, multidisciplinary street outreach team—the first such team in Canada—was designed in 2007 to enable rapid evaluation and treatment of street homeless clients with a wide range of disorders, to improve the ability of street outreach staff to manage these disorders and to contribute towards ending street homelessness related to illness and disability by streamlining access to housing, entitlements and health care. The development of the clinical street outreach team was an initiative undertaken by the City of Toronto's Streets to Homes program (City of Toronto 2009) to complement the network of city-funded programs providing street outreach.

21mdot consists of two part-time psychiatrists, one full-time nurse case manager, one full-time housing case manager, one full-time street outreach case manager and one part-time concurrent disorders specialist. This team composition was thought to include the content expertise and organizational resources required to address the needs of this population. Additional program partners include a community health centre that offers comprehensive primary care services and the provincially funded Ontario Disability Support Program that provides priority access to adjudication for income supports. mdot follows a Housing First philosophy, developed to meet the housing and treatment needs of the chronically homeless population (Shern et al. 2000; Tsemberis, Gulcur and Nakae 2004). Housing First views housing as a human right and involves providing homeless persons with immediate access to subsidized housing and case management supports. No preconditions, such as bringing substance abuse under control or being stabilized on medications, are imposed. Housing First supports access to housing concurrently with addressing immediate needs in other areas.

22Unlike the Pathways Housing First model, mdot does not provide long-term assertive community treatment, but rather offers transitional intensive case management until clients are housed and referred to appropriate long-term health services. This approach reserves the team expertise and resources for the engagement, housing and community connection of street homeless persons, transferring care to other agencies once these goals are achieved. This approach facilitates ongoing access to this highly specialized team for the street dwelling population. The team accepts referrals for clients whose needs exceed other street outreach teams' expertise and resources and who have unmet needs in one or more of the following areas: severe mental illness including severe substance abuse, developmental challenge or other acute medical needs.

23Outreach and client engagement focus on frequent contact with clients to identify and address immediate needs and a client-centred approach to service provision. Client assessment and case management are integrated and multidisciplinary. Each client is assigned to a primary case manager at intake but accesses team resources and expertise according to identified needs. The team of providers from different home agencies and professional backgrounds shares an integrated clinical record. Communication and collaboration between team members is fostered through regular team meetings. Clients are directed to one of the two partner hospitals for their acute care needs. Discharge planning is facilitated and coordinated by a close working relationship with hospital discharge planners of the partner hospitals. The team provides ongoing support to clients after housing placement until other community partners are able to engage them successfully into the appropriate level of long-term treatment, often many months after the original intake to the program.

Coordinated Access to Care for the Homeless (CATCH)

24In the absence of appropriate community-based health services, many homeless persons rely on hospital emergency department visits or in-patient hospitalizations for health care (Salit et al. 1998; McNiel and Binder 2005; D'Amore et al. 2001), which are not designed to address their needs comprehensively. When admitted to hospital, homeless persons have longer hospital stays with higher costs (Salit et al. 1998; Hwang et al. 2011). Unsurprisingly, the 2007 cihi report on Mental Health and Homelessness confirmed that mental illness and addictions were the most common reasons for homeless clients visiting emergency rooms or necessitating in-patient care in Canada (cihi 2007).

25Leveraging additional funding to address both local health priorities to decrease emergency room wait times and lengths of stay in hospital, as well as community-identified needs for better discharge planning and integration of hospital and community care, icha led the development of a coordinated access to care for the homeless program (catch). The program offers a centralized referral process for community-based health services for homeless persons presenting to hospital who are not able to access other services. catch aims to improve access to medical care, psychiatric care, peer support and case management and facilitate appropriate discharge planning of homeless persons with complex health needs. An additional program goal is to relieve pressure from emergency departments and in-patient units by coordinating hospital-based care with community-based homeless clinical and social services. The program, in addition to streamlining access to primary and psychiatric care, offers access to nursing, personal, peer support and transitional case management in partnership with other agencies, including a large community mental health agency, a homeless shelter and a consumer-driven community centre. It also leverages partnerships to offer facilitated access to disability income support to hospitalized homeless persons and a discharge planning checklist as a guide to hospital-based discharge planners.

26The program improves service coordination and hospital community integration and provides assertive outreach, transitional case management and linkage to the apporpriate level of needed support. Program participants are supported in navigating the complex system of services and supports already available to them and are linked to additional needed services as soon as it is feasible. catch clinicians provide transitional supports over a period of four to six months in most cases. The project team includes four full-time staff: an icha administrative coordinator/agency liaison, who processes referrals to the team members, and three transitional case managers, who provide outreach to three emergency department and in-patient units in downtown Toronto and the team physicians. The program enjoys the support of peer support workers, who accompany clients to appointments as needed.

Barriers and Facilitators

27icha strategies for creating local system change have included nurturing community partnerships, building community capacity, influencing the health care system and linking sectors and resources. Over time, several factors contributed to the growth of the association and collaborative program development, including physician funding on a competitive hourly remuneration rate, institutional support from the University of Toronto and St. Michael's Hospital, which facilitated physician recruitment and educational and research activities, and a shared vision with the City of Toronto's Support and Housing Administrative Division, the Toronto Drop-In Network and Toronto Social Services for enhanced access to comprehensive health services.

28Despite program growth, several barriers to program development emerged over the years, including a diverse and poorly resourced group of frontline homeless service providers; long standing tensions between health and community-based social services; lack of central planning for the various service components that homeless persons require access to; different privacy legislations binding health information custodians and social services providers; and cultural differences in some frontline homeless service settings, who offer institutional rather than recovery-oriented care by frontline staff with very limited mental health training or supervision.

29Despite these barriers, icha has been very successful in meeting its operational goals and priorities. Several strategies were successfully utilized for that purpose. To overcome resistance by social service providers, relationship building with frontline homeless service providers, their managers and service planners was an early icha priority. Extensive consultations and joint planning and program development, both within individual agencies and local homeless planning committees ensured buy-in for hosting clinics in key frontline agencies, as well as operational support for clinics by frontline agency staff. Partnerships were nurtured based on shared values, with the belief that each partner makes a unique and valuable contribution, resulting in power sharing and mutual benefit. Furthermore, icha leadership engaged municipal and provincial levels of government and local health networks to ensure planning meets and facilitates government identified priorities and contributes to overall system effectiveness. Helping align client centred care, frontline homeless agency needs and government priorities was very helpful in fostering partnerships and collaborations for innovative programming that spanned different sectors that do not traditionally work together. The ability to translate research findings into clinical programs was a critical aspect of developing effective relationships with these key stakeholders, informing system priorities and capitalizing on funding opportunities.

30To address different privacy requirements in the frontline settings served, careful planning and rollout of a web-based electronic medical record (emr) system, which provides role-based access to clinical notes, was undertaken. Finally, to address cultural differences in some settings, and further build community capacity, icha members strove to develop training seminars and workshops on a range of behavioural health topics and to provide a toolkit of knowledge and skills for frontline service providers who may have limited mental health training and supervision.

31In addition to these barriers, inter-professional team building, not only at the different clinic sites, but within the icha leadership team, was a significant early challenge. Team members, in light of their different training and experiences, held very diverse views of system priorities and strategies for system change or for meeting homeless clients' complex health and support needs. Learning to appreciate and embrace those differences, and creating organizational structures that allow for problem solving and transparent decision-making, have been instrumental for fostering healthy teams and programs, as has the commitment to high quality, evidence-informed care.

Lessons Learned and Future Directions

32Designing effective programs and minimizing barriers to access for homeless persons with mental illness continue to be major challenges for health service systems, which are plagued by limited resources and a high degree of fragmentation. icha has attempted to address some of these challenges through collaborative planning and program development, partnerships with stakeholders from various sectors and collaborative organizational program structures, with little new investment. Unlike traditional health care approaches, this effort to bring local system change has required collaboration by all key stakeholders, responsiveness to community identified priorities and focused efforts on frontline social service agency staff empowerment and capacity building. It has fostered relationships that involve mutual respect, equity and inclusiveness, recognizing the community as a resource and aiming for shared leadership and power in health program development. Lessons learned through these efforts are generalizable in many urban settings facing similar challenges.

33There are several advantages to the approach described above for planned system change. First, partnerships and collaborations can lead to improved access to a continuum of health, housing and income supports. Second, integrating primary and specialist mental health care in the frontline homeless settings addresses several system barriers: it avoids long waiting lists for mental health services; it improves coordination of primary care and mental health services and integration of medical care with social work and other frontline social services; it builds on the strengths of the partners, relieving pressures from other parts of the health care system; and it promotes academic–medical linkages and community development.

34Our efforts to date have highlighted the need for widespread system change and the important role that communities and researchers can play in this effort through joint exploration of system barriers and working collaboratively to identify the evidence base for guiding the systems change process. In addition to drawing attention to homeless health as a priority for reform in a system that values health equity, future directions in planning an appropriate and effective mix of treatment and support services for homeless persons with mental illness should consider several complimentary approaches. First, standardized and detailed needs assessments of social, clinical and rehabilitative problems should be conducted to identify the need for mental health services (Acosta and Toro 2000; Salize et al. 2001; Stergiopoulos et al. 2010b). Second, evidence-based practices should be integrated into housing and support services, such as Housing First approaches and Assertive Community Treatment (Shern et al. 2000; Tsembersis, Gulcur and Nakae 2004; Goldwell and Bender 2007). Last, but not least, systems-level coordination should be pursued to promote hospital–community integration, the integration of mental health with addictions treatment and the integration of mental health services with the rest of the health care system (Rosenheck, Resnick and Morrissey 2003; Durbin et al. 2006).

35Greater collaboration between agencies and sectors will be instrumental to better meet the goal of providing client-centred care to homeless persons with complex support needs. Finally, alternative funding models for medical care, to address the limitations of fee for service models for this population, should be considered across jurisdictions.

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Auteur

The Psychiatrist-in-Chief at St. Michael's Hospital and scientist at the Centre for Research on inner-city health in Toronto. Dr. Stergiopoulos's research focuses on the development and evaluation of community-based interventions to improve health outcomes among people who are homeless, and in particular those who frequently access mental health services

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